Recovery Housing Credit Request CLIENT INFORMATIONClient Name:* First Last Primary Counselor:*Select your counselor hereKelsey GreggChoice Pickins NewstromDavid SmithAva DrakeOtherCurrent Treatment Attendance:* 5 Days 4 Days 3 Days 2 Days 1 Day EOP HOUSING PROVIDER & PAYMENT INFONOTE: We pay your residence once per month at the end of the month.I am requesting payment for the month of:Month*Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberCurrent Recovery Residence:* Move in Date:* MM slash DD slash YYYY Do you have any plans to move in the next 60 days?* No Yes Not Sure ATTENDANCE STATUSDid you attendance all scheduled group and individual sessions during the past month?* Yes No How many did you miss? ACKNOWLEDGEMENT OF HOUSING CREDIT TERMSHousing Credit Client Terms*All clients are subject to a two-week “waiting period” before they receive a rent credit. Assuming all services are completed during that time, payment is made back to the intake date. Eligibility is determined by treatment attendance, and 2 or more weeks of inconsistent attendance may result in your becoming ineligible for the housing credit. Housing credits are automatically reduced as you reduce your treatment hours. It is your responsibility to pay any difference between what Elite Recovery pays and your total housing fees. Here are the current credit amounts according to attendance hours: 80+ Hours per month = $550 Credit 64+ Hours per month = $450 Credit 48+ Hours per month = $350 Credit 36+ Hours per month = $250 Credit 20+ Hours per month = $150 Credit Extended Care EOP = $100 Credit Housing credits are not a guarantee and may be reduced and rescinded. Please see your counselor with questions! I agree to the housing credit terms and request payment for my residence.Client Signature*